Hirak Dutta

Executive Director
Oil Industry Safety Directorate

Size of the Hydrocarbon Industry in India

Hydrocarbon industry in India

India is the 4th largest consumer (at 524 Million Metric Tonnes of Oil
Equivalent) in the year 2010; after China, US & Russia.

Oil Installations operate at high temperature & pressure;

highly hazardous & inflammable HCs.

handles

Oil Industry plays a vital role in providing energy security and

contributes towards the overall growth of the country.

Therefore preservation and safety of these vital National assets are of

paramount importance.

Accidents do not
happen just like that
Plant provides lot of signals
We do not pick up those

Why do Accidents happen

Improper operations

Poor reliability Maintenance

Poor Supervision

Disregard to the System

Leadership: right people in right job??
Knowledge Gap

Look at the recent Accidents

Chevron USA California

(Investigation ON but prima-facie)

Fire in CDU
Leak in process pipeline
While removing insulation in HSD line Fire took place
Reportedly HSD line was badly corroded
Inspection recommended replacement

Root Cause

Disregard to the extant systems & procedures.

Amuay Refinery, Venezuela (Investigation

ON but prima-facie)

Massive fire in the unit

46 lives lost
Leakage of gas from the gas line
Corrosion in the gas carrying lines
Hydrocarbon detection : were they functional?
Delay in sounding alarm

Root Cause

Disregard to the extant systems & procedures.

Poor Maintenance.

Jaipur Fire

11 lives lost
Rs. 300 Crores property loss
Fire took place during PLT
MS from Sanganer to BPCL
Spilling of MS during Hammer Blind reversal
Huge MS spill Vapor cloud formation
Why the MOV from Control room didnt close
The cable was cut MOV couldnt be activated from C/R.

Root Cause

Disregard to the extant systems & procedures.

Failure of process safety mgmt. system

Three recent LPG related accident in

OMCs

Case 1:Fatal Accident (1 fatality, 1 injury).

Case 2:Huge property loss.
Case 3: High potential near miss incident (could have
resulted in disaster).
Statutory action initiated.

Root cause of such incidents at LPG

plants

Poor health of the metallic loading arms

No maintenance / no spares available
Poor supervision
Disregards to the System
* Cold flaring not done
* Driver virtually in charge of operation
* Lackadaisical approach

Major Incidents : (In plant)

Miscreants Activity
5%

Slip/fall, Negligence
Driving
19%

78 % due to
Disregard to extant
Systems &
Procedures

Non adherence to
SOP
36%

Lack of Supervision
10%

Non adherence to
Work permit
system
11%
Improper Earthing
2%

Equipment Failure
17%

Fatalities - (In plant)

Slip/fall,
Negligence,
16%
Lack of Supervision
16%

Non adherence to
Work permit
system
24%

92%
incidents
due to
disregard to
systems.

Non adherence to
SOP
36%

Equipment Failure
8%

Reasons for accidents

Design flaws not rectified; HAZOP study carried out but hazards &
remedial actions were not identified.

Improper focus on Asset Integrity Management; poor reliability.

Disregard to the extant systems & procedures.

Violation of standard operating procedure.

Knowledge gap & poor supervision.

What should be done??

What should be done??

Penny wise, pound foolish

Production First philosophy - Penny pinching approach leading to
improper maintenance & asset integrity
Knowledge gap
Severe accidents are too rare perception focus on low
probabilities and not high consequences

Learn from the mistakes

Consequences of minor error in Oil industry is horrendous loss of
life and property
Same mistakes are being committed time & again.
Fatal accident from H2S exposure & LPG related happened in
many locations & is not uncommon.

What should be done??

Focus on Asset Integrity Management

Avoid delaying ATAs to show improved MTBF
Dont postpone M&I of tanks; adhere to the schedule
Improve reliability thru preventive & predictive
maintenance.

Take care of Human Assets

State of the art technology is a must but what about its

proper assimilation.

Listen to dissent views; encourage.

What should be done??

Role of Top management

Involvement of senior executives gives teeth to bite not only to

the safety but to productivity as well.

Belief that Accidents can be prevented.

Walk the talk.

Encourage Internal Disclosures

Cult of the industry is to discourage the disclosure of incidents &

near-misses

A series of small incidents and their non-disclosure inevitably

leads to big incidents.

Bad news is Good news.

Reward the person carrying the bad news.

Risk Assessment & Hazard Study

Accident Incident Analysis

Adherence to System & Procedures

Safety
Management of
Change

Managing Asset Integrity

Employee Engagement

Corner Stones of Safety

Thank you